Acute Mastoiditis in Children – A National Study in Sweden

Abstract: One of the greatest threats to society today is the development of bacterial resistance to antibiotics. It is commonly accepted that this is mainly due to the use of antibiotics. Acute otitis media (AOM) is responsible for the highest number of antibiotic prescriptions to children although it is in most cases a self-limiting disease. Nevertheless, complications do occur in some case and the most common complication is acute mastoiditis (AM). Treatment guidelines advocating the restrictive use of antibiotics in uncomplicated AOM have been implemented hoping to slow down the development of resistance to antibiotics. This has led to concerns that an increase of complications will arise. Although AOM is extremely common in early childhood, only 20–60 cases of AM in children are encountered per year in Sweden. In the pre-antibiotic era AM was often lethal and the use of antibiotics has revolutionized the clinical course of severe AOM and AM, radically reducing the rate of complications and mortality. In addition to the new guidelines, in the year 2009, immunisation with pneumococcal conjugate vaccine (PCV) against the most invasive serotypes of Streptococcus pneumoniae, the most common bacteria causing AOM as well as AM, was introduced into the standard immunisation schedule in Sweden. The national study “Mastoiditis in Sweden”, which formed the basis for the research presented in this thesis, gives a good picture of Swedish paediatric patients suffering from AM. The different ways in which AM symptoms are expressed and their development in different age groups are well described in Paper 1. Different surgical methods for treating subperiosteal abscesses were evaluated in Paper 2. It was found that needle aspiration and/or incision to treat SA had no adverse effects when compared to mastoidectomy. Possible effects of the recently introduced immunisation against pneumococci were investigated in the third study (Paper 3). PCV did not offer a complete protection against the serotypes included in the vaccines, even in fully immunised children. Finally, the effects of the altered guidelines on AOM treatment were explored in an attempt to identify risk factors for AM (Paper 4). No overlooked possible risk factors for AM could be identified. Unfortunately, the retroauricular findings indicating an AM, were found to be overlooked by physicians at the primary assessment of some children, which caused a delayed treatment. Thus the AOM treatment guidelines appear to be sufficient, and the greatest challenge lies in detecting complications arising from AOM.